Trends in Emergency Department Exam Medicare Reimbursements Between 2010 and 2018

Background: As the Medicare population continues to grow, financial pressure is placed upon hospitals, physicians, and other providers as the payer mix has an increasing proportion of Medicare patients. Objective: The purpose of this study was to further the understanding of reimbursement trends surrounding the five levels of emergency department (ED) examinations (CPT codes 99281-99285) from 2010 to 2018 and determine how they have changed with respect to each procedure. Methods: CPT codes were filtered into the 2010 and 2018 Physician/Supplier Procedure Summaries from the Centers for Medicare and Medicaid Services’ website to gather data on emergency physician submissions and Medicare denials and payments. Results: In 2010, 15,669,196 ED examinations were submitted to Medicare for $7,628,693,382 while in 2018, 16,432,184 ED examinations were submitted for $14,522,456,383. Despite an increase of $397/submission made by emergency physicians, Medicare paid 20.5% of the submitted charges in 2010 for ED examinations and 11.9% in 2018. The denial rate in 2018 was highest for level I ED examinations (11.3%), and the lowest for level V examinations (5.1%). The utilization of level V ED examinations increased 22.3% from 2010 to 2018, while the utilization of the others decreased. Of the five levels of ED examinations, only the level I examination did not exhibit a decrease. Conclusions: From 2010 to 2018, emergency physicians charged a higher amount for ED examinations, yet Medicare reimbursement accounted for a smaller proportion of these charges, resulting in less payment per submission for the four most common levels. Downward trends in Medicare reimbursement may place financial burdens that could potentially hamper healthcare outcomes.


Introduction
General trends in reimbursement have shown an overall decrease in reimbursement for healthcare services.This overall decrease in reimbursement has been largely attributed to the Deficit Reduction Omnibus Reconciliation Act of 2005 and the Medicare Access and Children's Health Insurance Program (CHIP) Reauthorization Act of 2015 [1,2].Currently, United States healthcare billing utilizes Current Procedural Terminology (CPT) codes to categorize procedures and decide reimbursement dollar amounts.Specifically in emergency medicine (EM), studies have shown a decrease in Medicare reimbursement for particular procedures [3,4].
Additionally, recent media has called out EM for "upcoding" procedures, namely, categorizing minor, less serious conditions as serious to upcharge [5].With these recent controversial allegations coupled with the general decreasing trends in Medicare reimbursement, understanding how reimbursement has changed in the five levels of emergency department (ED) examinations over the years is especially important.As the Medicare population continues to grow, financial pressure is placed upon hospitals, physicians, and other providers as the payer mix has an increasing proportion of Medicare patients.Physicians are under pressure from many different sources, such as patients wanting to maximize their visit length, or hospital administration encouraging shorter visits with patients.
The purpose of this study was to further the understanding of reimbursement trends surrounding the five levels of ED examinations (CPT codes 99281-99285) from 2010 to 2018 and determine how they have changed with respect to each procedure.This study looks at trends in facility price, facility limiting charges, relative value units (RVUs), submitted and denied services, physician-submitted charges, and Medicareallowed charges.

Materials And Methods
The American College of Emergency Physicians (ACEP)'s top 20 most common ED reimbursement code list was used to analyze ED examination services, of which all five levels of ED examinations (CPT codes 99281-99285) appeared, with levels II-V in the top five.These were then filtered into the 2010 and 2018 Physician/Supplier Procedure Summaries from the Centers for Medicare and Medicaid Services' website to gather data on emergency physician (provider code 93) submissions and Medicare denials and payments between the years.According to the Department of Health and Human Services (DHHS), approximately 20% of ED visits in 2010 were Medicare patients.In 2018, approximately 24.5% of ED visits were Medicare patients [6].
To review Medicare reimbursement data, we utilized the Physician Fee Schedule Look-Up Tool from the Centers for Medicare and Medicaid Services.We filtered the ED examination levels I-V into the 2010 and 2018 Physician/Supplier Procedure Summaries to gather data on emergency physicians, in particular, by using provider code 93 submissions.Additionally, we abstracted data on Medicare submissions, denials, and payments between the years.
According to the ACEPs, ED examination levels I-V were in the top 20 most common ED reimbursement code list [7].While there is no national standard for hospital assignment of EM code levels, ACEP provides guidelines for facility billing to categorize ED exams into one of the five levels [8].The determination of the ED examination level is based solely on "possible interventions" based on the difficulty of procedures [8].
Each level includes the possibility of interventions from the previous level with the addition of other services.Possible interventions for level I examinations include initial assessment, dressing changes, and suture removals [8].For level II examinations, examples include tests done by ED staff (e.g., urine dip), elastic bandage application, and minor laceration repairs [8].Level III examination interventions can include receipt of an ambulance patient, nebulizer treatment, and joint aspiration [8].For level IV examinations, examples of interventions can include the preparation of two diagnostic tests, preparation for X-ray or special imaging, and admission of infusions [8].Finally, level V examinations can include frequent monitoring of multiple vital signs, administration of blood transfusion, and central line insertions [8].
For each of the five CPT codes (99281, 99282, 99283, 99284, and 99285), the facility price (fee assigned to services provided in facility settings), facility limiting charge (maximum value charged when the provider does not participate in Medicare), RVUs (set with a fee schedule by measuring relative resources, time, and effort used to provide a service), number of services denied, number of submissions, physician submitted charges, and Medicare allowed charges were obtained for each year.The dollar amounts were adjusted for inflation to 2018 USD based on the United States Consumer Price Index (CPI).
To analyze the extracted data, descriptive statistics were used to determine changes, proportions, and total amounts.

Results
The results are summarized in Table

Discussion
This study found that the number of physician submissions increased between 2010 and 2018, while the proportion of services denied also increased in this time period.Furthermore, the proportion of total charges allowed between 2010 and 2018 also decreased by approximately 42%.Notably, while the utilization of examination levels I-IV decreased, exam level V increased by approximately 17%.
While reimbursement trends are decreasing across specialties [9][10][11], EM decreases are relevant in particular due to EM physicians being tasked with seeing all patients who present to the ED with an emergent condition to abide by the Emergency Medical Treatment and Active Labor Act (EMTALA) [12].Therefore, EM physicians cannot choose to only see patients with private insurance, rather than Medicare.Between 2009 and 2018, the proportion of ED visits with patients having private insurance decreased, while those with Medicare increased [13].This can account for the decrease in income of many physicians after accounting for inflation [14].
Additionally, this study found that the utilization of level V examinations increased, while the rest of the examination levels decreased.Level V examinations have the highest price and RVU as compared to the lower levels, which happened to correlate with the increase in utilization of these examinations.While the controversy over upcoding continues, research suggests that some of the excesses in billing may stem from upcoding [15].Pressure to upcode may come from hospital leadership as well as insurance payment incentives [15].This phenomenon may not be a contributor to the changes in CPT coding in this study

TABLE 1 : Comparison of pricing, services, and submissions for levels I-V exams between 2010 (adjusting for inflation) and 2018
Of the five levels of ED examinations, only the least common level I examination did not exhibit a decrease in Medicare payment in that time span.Given this decrease, the total payment for all ED examinations was cut by $17,542,385 from 2010 to 2018.